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<br /> <br /> Client Application <br />(Shaded areas are for internal use only) <br />Partner Code: <br /> <br />Account Representative: Mark Submission Date: 3/21/2017 <br />Card Readers Quantity: 1 Price: $ 0 Target Live Date: 5/1/2017 <br />Client Profile <br />Client Legal Name as filed with the IRS: Federal Tax ID: <br />Kittitas County, WA <br />DBA: Kittitas County Public Health <br />Address: 507 N Nanum St Suite 102 <br />City: Ellensburg State: WA Zip: 98926 <br />Website Address: http://www.co.kittitas.wa.us/health/ Phone # to display on customer receipts: 509-962-7515 <br />Contacts <br />Primary Contact Name: Primary Phone #: Primary Email: <br />Robin Read 509-962-7515 publichealth@co.kittitas.wa.us <br />Accounting Contact: Accounting Phone #: Accounting Email: <br />Brett Wachsmith, Treasurer 509-962-7535 treasurer@co.kittitas.wa.us <br />Fee Summary <br />2.5% $2.00 min (all card types) <br />echeck $2.00 flat no min <br />Couinty passing fee onto customer <br />No costs to County <br />Product Summary <br />Software Partner: Smartgov <br />Product Name <br />Total Annual <br />Collections for <br />Payment Type <br />Average <br />Payment <br />Amount <br />Highest <br />Payment <br />Amount <br />1 Permits $ $ $ <br />2 $ $ $ <br />3 $ $ $ <br />4 $ $ $ <br />5 $ $ $ <br />Banking Summary <br />Deposit Structure: Net Settlement Debit <br />Product Name (or # from above) Bank Name Routing # Account # Acct Type <br />1 US Bank Check. Savings <br /> Check. Savings <br /> Check. Savings <br /> Check. Savings <br /> Check. Savings <br />Notes <br />Web Ingtegration with Smartgov <br />Counter manual <br /> <br /> <br /> <br />Signature <br />The undersigned agrees to abide by the Terms and Conditions of the Global Merchant Services Agreement, viewable at www.pointandpay.com/agreement.   <br /> <br /> Administrator <br />Signature Title <br />Robin Read <br />Print Name Date <br />